Robert Finn

SAN FRANCISCO — If left untreated, lichen sclerosis can lead to scarring, destruction of normal vulvar architecture, and even skin cancer, but if caught early and treated properly, complete remission is possible.

“It's a wonderful disease to treat,” said Dr. Erika Klemperer, a dermatologist in private practice in Santa Barbara, Calif. “You can make these patients better.”

The first step is recognizing when the diagnosis is lichen sclerosis and when it is something else, she said at a meeting sponsored by Skin Disease Education Foundation (SDEF).

Patients will complain of pruritus, but they will avoid scratching because it is too painful. In contrast, vulvar lichen simplex chronicus results in an itch that is pleasurable to scratch.

They also will report dyspareunia, dysuria, and painful bowel movements. And patients will either be prepubertal or postmenopausal, she said.

“You've got to thoroughly look at the vulva to pick up the early signs of disease,” Dr. Klemperer said. “You have to be comfortable looking in this area so we can help these women. You've got to make sure you spread the lips. And not just pulling the labia apart. You really have to manipulate the folds, lift up the clitoral hood.”

If it is lichen sclerosis, pallor and edema can be seen, in addition to well-demarcated pearly white plaques that tend to be symmetric and arranged in a figure eight around the vulva, perineum, and perianal regions. The plaques will have a distinctive texture—either a dull, glazed, waxy texture; a very shiny texture; or a fine, crinkled texture.

Purpura, fissures, and fragility also are common. “Purpura is a key diagnostic sign,” Dr. Klemperer said. “If you see purpura, think lichen sclerosis.”

Edema around the clitoral hood is another early finding, and in more advanced cases there may be secondary lichenification and extensive scarring.

If unsure whether it is vulvar lichen sclerosis, look elsewhere on the patient's body. About 10%–15% of women with the condition will have extragenital disease, most often on the upper trunk. Lesions in that location can confirm an uncertain diagnosis, she said.

In addition to treating the secondary infections, “Ultrapotent topical steroid ointments are absolutely the treatment of choice for lichen sclerosis,” Dr. Klemperer said. “They've been proven not only to improve symptoms but also to actually affect both clinical and histologic disease. You can reverse all the changes that we talked about except for the scarring.” (See sidebar.)

Although treatment needs to be individualized, Dr. Klemperer tends to start with twice-daily treatment for the first month and once or twice daily thereafter. She said that she typically will treat for 12 weeks, but this can vary.

Relapses are common when treatment is stopped, so Dr. Klemperer now recommends maintenance treatment. “The studies have not been done yet to show what that ideal [maintenance] treatment is, but most of us in the vulvar derm world do 1–3 nights weekly of mild to potent topical steroid ointments,” she said. “And then I see them back in 3 months to see how they're doing.” Educating the patient on the need for these treatments also is critical. “I tell them why we're doing this,” Dr. Klemperer said. “We're trying to prevent further scarring. Lichen sclerosis definitely has an association with squamous cell carcinoma. My goal is to prevent that.”

Dr. Klemperer stated that she had no conflicts of interest related to her presentation. SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Appropriate Use of Ultrapotents Is Key

Ultrapotent topical steroids can be used safely and effectively in the vulvar area, but appropriate use is key, Dr. Klemperer said.

She offered the following topical steroid safety tips:

▸ Ultrapotents should not be used for psoriasis or a mild contact dermatitis. Desonide ointment or other lower-potency topicals will do the trick.

▸ Use ointments rather than creams because they are more occlusive.

▸ Monitor patients monthly for side effects. Although mucous membranes are relatively resistant to steroid side effects, this is not true of skin in the groin or perineum, or around the buttocks.

▸ Stress to patients that ultrapotent steroids should be used once or twice daily, never more.

▸ Monitor the quantity that patients use. “They should not be going through a 30-g tube in less than 3 months. If they are, they're putting on much too much.”

▸ Perform a biopsy on a persistent hyperkeratotic, ulcerated, or nonresponsive area.

SAN FRANCISCO — If left untreated, lichen sclerosis can lead to scarring, destruction of normal vulvar architecture, and even skin cancer, but if caught early and treated properly, complete remission is possible.

“It's a wonderful disease to treat,” said Dr. Erika Klemperer, a dermatologist in private practice in Santa Barbara, Calif. “You can make these patients better.”

The first step is recognizing when the diagnosis is lichen sclerosis and when it is something else, she said at a meeting sponsored by Skin Disease Education Foundation (SDEF).

Patients will complain of pruritus, but they will avoid scratching because it is too painful. In contrast, vulvar lichen simplex chronicus results in an itch that is pleasurable to scratch.

They also will report dyspareunia, dysuria, and painful bowel movements. And patients will either be prepubertal or postmenopausal, she said.

“You've got to thoroughly look at the vulva to pick up the early signs of disease,” Dr. Klemperer said. “You have to be comfortable looking in this area so we can help these women. You've got to make sure you spread the lips. And not just pulling the labia apart. You really have to manipulate the folds, lift up the clitoral hood.”

If it is lichen sclerosis, pallor and edema can be seen, in addition to well-demarcated pearly white plaques that tend to be symmetric and arranged in a figure eight around the vulva, perineum, and perianal regions. The plaques will have a distinctive texture—either a dull, glazed, waxy texture; a very shiny texture; or a fine, crinkled texture.

Purpura, fissures, and fragility also are common. “Purpura is a key diagnostic sign,” Dr. Klemperer said. “If you see purpura, think lichen sclerosis.”

Edema around the clitoral hood is another early finding, and in more advanced cases there may be secondary lichenification and extensive scarring.

If unsure whether it is vulvar lichen sclerosis, look elsewhere on the patient's body. About 10%–15% of women with the condition will have extragenital disease, most often on the upper trunk. Lesions in that location can confirm an uncertain diagnosis, she said.

In addition to treating the secondary infections, “Ultrapotent topical steroid ointments are absolutely the treatment of choice for lichen sclerosis,” Dr. Klemperer said. “They've been proven not only to improve symptoms but also to actually affect both clinical and histologic disease. You can reverse all the changes that we talked about except for the scarring.” (See sidebar.)

Although treatment needs to be individualized, Dr. Klemperer tends to start with twice-daily treatment for the first month and once or twice daily thereafter. She said that she typically will treat for 12 weeks, but this can vary.

Relapses are common when treatment is stopped, so Dr. Klemperer now recommends maintenance treatment. “The studies have not been done yet to show what that ideal [maintenance] treatment is, but most of us in the vulvar derm world do 1–3 nights weekly of mild to potent topical steroid ointments,” she said. “And then I see them back in 3 months to see how they're doing.” Educating the patient on the need for these treatments also is critical. “I tell them why we're doing this,” Dr. Klemperer said. “We're trying to prevent further scarring. Lichen sclerosis definitely has an association with squamous cell carcinoma. My goal is to prevent that.”

Dr. Klemperer stated that she had no conflicts of interest related to her presentation. SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Appropriate Use of Ultrapotents Is Key

Ultrapotent topical steroids can be used safely and effectively in the vulvar area, but appropriate use is key, Dr. Klemperer said.

She offered the following topical steroid safety tips:

▸ Ultrapotents should not be used for psoriasis or a mild contact dermatitis. Desonide ointment or other lower-potency topicals will do the trick.

▸ Use ointments rather than creams because they are more occlusive.

▸ Monitor patients monthly for side effects. Although mucous membranes are relatively resistant to steroid side effects, this is not true of skin in the groin or perineum, or around the buttocks.

▸ Stress to patients that ultrapotent steroids should be used once or twice daily, never more.

▸ Monitor the quantity that patients use. “They should not be going through a 30-g tube in less than 3 months. If they are, they're putting on much too much.”

▸ Perform a biopsy on a persistent hyperkeratotic, ulcerated, or nonresponsive area.

SAN FRANCISCO — If left untreated, lichen sclerosis can lead to scarring, destruction of normal vulvar architecture, and even skin cancer, but if caught early and treated properly, complete remission is possible.

“It's a wonderful disease to treat,” said Dr. Erika Klemperer, a dermatologist in private practice in Santa Barbara, Calif. “You can make these patients better.”

The first step is recognizing when the diagnosis is lichen sclerosis and when it is something else, she said at a meeting sponsored by Skin Disease Education Foundation (SDEF).

Patients will complain of pruritus, but they will avoid scratching because it is too painful. In contrast, vulvar lichen simplex chronicus results in an itch that is pleasurable to scratch.

They also will report dyspareunia, dysuria, and painful bowel movements. And patients will either be prepubertal or postmenopausal, she said.

“You've got to thoroughly look at the vulva to pick up the early signs of disease,” Dr. Klemperer said. “You have to be comfortable looking in this area so we can help these women. You've got to make sure you spread the lips. And not just pulling the labia apart. You really have to manipulate the folds, lift up the clitoral hood.”

If it is lichen sclerosis, pallor and edema can be seen, in addition to well-demarcated pearly white plaques that tend to be symmetric and arranged in a figure eight around the vulva, perineum, and perianal regions. The plaques will have a distinctive texture—either a dull, glazed, waxy texture; a very shiny texture; or a fine, crinkled texture.

Purpura, fissures, and fragility also are common. “Purpura is a key diagnostic sign,” Dr. Klemperer said. “If you see purpura, think lichen sclerosis.”

Edema around the clitoral hood is another early finding, and in more advanced cases there may be secondary lichenification and extensive scarring.

If unsure whether it is vulvar lichen sclerosis, look elsewhere on the patient's body. About 10%–15% of women with the condition will have extragenital disease, most often on the upper trunk. Lesions in that location can confirm an uncertain diagnosis, she said.

In addition to treating the secondary infections, “Ultrapotent topical steroid ointments are absolutely the treatment of choice for lichen sclerosis,” Dr. Klemperer said. “They've been proven not only to improve symptoms but also to actually affect both clinical and histologic disease. You can reverse all the changes that we talked about except for the scarring.” (See sidebar.)

Although treatment needs to be individualized, Dr. Klemperer tends to start with twice-daily treatment for the first month and once or twice daily thereafter. She said that she typically will treat for 12 weeks, but this can vary.

Relapses are common when treatment is stopped, so Dr. Klemperer now recommends maintenance treatment. “The studies have not been done yet to show what that ideal [maintenance] treatment is, but most of us in the vulvar derm world do 1–3 nights weekly of mild to potent topical steroid ointments,” she said. “And then I see them back in 3 months to see how they're doing.” Educating the patient on the need for these treatments also is critical. “I tell them why we're doing this,” Dr. Klemperer said. “We're trying to prevent further scarring. Lichen sclerosis definitely has an association with squamous cell carcinoma. My goal is to prevent that.”

Dr. Klemperer stated that she had no conflicts of interest related to her presentation. SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Appropriate Use of Ultrapotents Is Key

Ultrapotent topical steroids can be used safely and effectively in the vulvar area, but appropriate use is key, Dr. Klemperer said.

She offered the following topical steroid safety tips:

▸ Ultrapotents should not be used for psoriasis or a mild contact dermatitis. Desonide ointment or other lower-potency topicals will do the trick.

▸ Use ointments rather than creams because they are more occlusive.

▸ Monitor patients monthly for side effects. Although mucous membranes are relatively resistant to steroid side effects, this is not true of skin in the groin or perineum, or around the buttocks.

▸ Stress to patients that ultrapotent steroids should be used once or twice daily, never more.

▸ Monitor the quantity that patients use. “They should not be going through a 30-g tube in less than 3 months. If they are, they're putting on much too much.”

▸ Perform a biopsy on a persistent hyperkeratotic, ulcerated, or nonresponsive area.

HONOLULU – The “digital divide” separating society's haves and have-nots may not be as deep as many fear, according to a study of 120 parents of adolescent patients and the patients themselves.

In a survey, more than 60% of parents and adolescents of low socioeconomic status (SES) from one Boston pediatric practice indicated a willingness to contact physicians via e-mail if given the option, according to Dr. Tarissa Mitchell of Boston Medical Center.

Among the survey respondents, 66% stated that they had access to e-mail and/or computers at home. But only 19% of the parents had their health care provider's e-mail address, and only 3% of them had ever used e-mail to contact their provider.

Dr. Mitchell and Dr. Shikha G. Anand of the Whittier Street Health Center, Roxbury, Mass., conducted a convenience sample survey of 120 parents of adolescent patients and the adolescent patients who were above the age of 13 at an urban community health center in Boston over a 4-month period. At that center, five pediatric providers serve 3,876 low SES children, 84% of whom are publicly insured and 82% of whom self-identify as black or Hispanic.

Compared with respondents without e-mail availability at home, those with home e-mail availability were significantly more willing to contact their physicians: 77%, compared with 33%. And respondents who used e-mail more frequently also were significantly more willing to contact their provider this way.

For example, among respondents whose e-mail was always on, 89% were willing to e-mail their physicians. This declined to 60% among respondents who used e-mail only weekly and to 43% of those who used e-mail monthly or less frequently than that, Dr. Mitchell and Dr. Anand wrote in a poster presented at the annual meeting of the Pediatric Academic Societies.

Only 13% of the respondents stated that they would never use e-mail to communicate with their provider.

The most common reason that they gave was a desire to telephone the office, but they also cited lack of access to e-mail, difficulty with the English language, concerns over bothering the doctor with e-mails, and an expectation of slower response time.

In addition, 33% of the entire survey population expressed concern that e-mail may not be private and could be reviewed by individuals other than their health care provider.

Dr. Mitchell and Dr. Anand stated that they had no conflicts of interest related to this presentation.

HONOLULU – The “digital divide” separating society's haves and have-nots may not be as deep as many fear, according to a study of 120 parents of adolescent patients and the patients themselves.

In a survey, more than 60% of parents and adolescents of low socioeconomic status (SES) from one Boston pediatric practice indicated a willingness to contact physicians via e-mail if given the option, according to Dr. Tarissa Mitchell of Boston Medical Center.

Among the survey respondents, 66% stated that they had access to e-mail and/or computers at home. But only 19% of the parents had their health care provider's e-mail address, and only 3% of them had ever used e-mail to contact their provider.

Dr. Mitchell and Dr. Shikha G. Anand of the Whittier Street Health Center, Roxbury, Mass., conducted a convenience sample survey of 120 parents of adolescent patients and the adolescent patients who were above the age of 13 at an urban community health center in Boston over a 4-month period. At that center, five pediatric providers serve 3,876 low SES children, 84% of whom are publicly insured and 82% of whom self-identify as black or Hispanic.

Compared with respondents without e-mail availability at home, those with home e-mail availability were significantly more willing to contact their physicians: 77%, compared with 33%. And respondents who used e-mail more frequently also were significantly more willing to contact their provider this way.

For example, among respondents whose e-mail was always on, 89% were willing to e-mail their physicians. This declined to 60% among respondents who used e-mail only weekly and to 43% of those who used e-mail monthly or less frequently than that, Dr. Mitchell and Dr. Anand wrote in a poster presented at the annual meeting of the Pediatric Academic Societies.

Only 13% of the respondents stated that they would never use e-mail to communicate with their provider.

The most common reason that they gave was a desire to telephone the office, but they also cited lack of access to e-mail, difficulty with the English language, concerns over bothering the doctor with e-mails, and an expectation of slower response time.

In addition, 33% of the entire survey population expressed concern that e-mail may not be private and could be reviewed by individuals other than their health care provider.

Dr. Mitchell and Dr. Anand stated that they had no conflicts of interest related to this presentation.

HONOLULU – The “digital divide” separating society's haves and have-nots may not be as deep as many fear, according to a study of 120 parents of adolescent patients and the patients themselves.

In a survey, more than 60% of parents and adolescents of low socioeconomic status (SES) from one Boston pediatric practice indicated a willingness to contact physicians via e-mail if given the option, according to Dr. Tarissa Mitchell of Boston Medical Center.

Among the survey respondents, 66% stated that they had access to e-mail and/or computers at home. But only 19% of the parents had their health care provider's e-mail address, and only 3% of them had ever used e-mail to contact their provider.

Dr. Mitchell and Dr. Shikha G. Anand of the Whittier Street Health Center, Roxbury, Mass., conducted a convenience sample survey of 120 parents of adolescent patients and the adolescent patients who were above the age of 13 at an urban community health center in Boston over a 4-month period. At that center, five pediatric providers serve 3,876 low SES children, 84% of whom are publicly insured and 82% of whom self-identify as black or Hispanic.

Compared with respondents without e-mail availability at home, those with home e-mail availability were significantly more willing to contact their physicians: 77%, compared with 33%. And respondents who used e-mail more frequently also were significantly more willing to contact their provider this way.

For example, among respondents whose e-mail was always on, 89% were willing to e-mail their physicians. This declined to 60% among respondents who used e-mail only weekly and to 43% of those who used e-mail monthly or less frequently than that, Dr. Mitchell and Dr. Anand wrote in a poster presented at the annual meeting of the Pediatric Academic Societies.

Only 13% of the respondents stated that they would never use e-mail to communicate with their provider.

The most common reason that they gave was a desire to telephone the office, but they also cited lack of access to e-mail, difficulty with the English language, concerns over bothering the doctor with e-mails, and an expectation of slower response time.

In addition, 33% of the entire survey population expressed concern that e-mail may not be private and could be reviewed by individuals other than their health care provider.

Dr. Mitchell and Dr. Anand stated that they had no conflicts of interest related to this presentation.

SAN FRANCISCO — Nearly one-third of trauma patients reported at least some degree of sexual dysfunction a year after injury, according to a multicenter prospective cohort study.

This rate is about double that of healthy patients, and triple that of healthy patients under the age of 50 years, Dr. Matthew D. Sorenson said at the annual clinical conference of the American College of Surgeons.

“In fact, we found that a moderate to severe traumatic injury imparts a risk of sexual dysfunction above and beyond the risk that may be imparted by known risk factors for sexual dysfunction, such as increasing age, diabetes, and lower socioeconomic status,” Dr. Sorensen of the University of Washington, Seattle, said in a prepared statement.

The study was based on data from the National Study on the Costs and Outcomes of Trauma (NSCOT), which included 69 hospitals from 15 geographic regions in the United States. Patients were between 18 and 84 years of age and had moderate to severe injuries. A year following their injuries patients completed a 45-minute phone interview.

Of 10,122 patients, 3,087 (31%) answered yes to the question, “As a result of your physical health, were you limited in your ability to have sexual relations?”

Investigators then assessed whether those patients had mild or severe sexual dysfunction. For 57% of the patients with sexual dysfunction, that dysfunction was severe.

The investigators performed a multivariate analysis, adjusting for gender, race, marital status, mechanism of injury, and genitourinary injury to determine the independent predictors of severe sexual dysfunction.

As expected, spinal cord injury emerged as the best predictor of severe sexual dysfunction, with an adjusted relative risk of 3.7. But with the relative risk of 2.3, very severe injury turned out to be a better predictor of severe sexual dysfunction than did either pelvic fracture or a lower extremity fracture, both of which had relative risks of 1.5.

Other significant independent predictors of severe sexual dysfunction were age, global health status, diabetes, and income category.

Chronic pain proved to be another independent predictor of severe sexual dysfunction after the investigators adjusted for age, gender, race, comorbidities, self-reported health, mechanism of injury, injury severity, pelvic fracture, spinal cord injury, lower extremity fracture, and genitourinary injury.

Patients with pain grade II (high intensity) had 2.4 times the risk of severe sexual dysfunction than those with no pain. That adjusted odds ratio increased to 7.26 among patients with pain grade III (moderately limiting), and to 36.4 among patients with pain grade IV (severely limiting).

The investigators also found an independent association between sexual dysfunction and depression. Patients with depressive symptoms had more than seven times the risk of severe sexual dysfunction than those with no depressive symptoms. However, in response to a question from the audience, Dr. Sorensen said, “Whether it's the sexual dysfunction that's causing depression or the depression that's causing sexual dysfunction, that's all really unknown.”

The prepared statement quoted Dr. Sorensen as saying that these findings should serve as a wake-up call for physicians who treat trauma patients. “For most practitioners, both primary care and trauma physicians, sexual function is not on their radar screen, and most often they think of erectile dysfunction in men. … But sexual dysfunction is a major determinant of quality of life, impacts both men and women, and if physicians don't ask patients about their sexual health, the patients are unlikely to bring it up. This is something physicians should be asking their patients about, because there are excellent medications that work in the majority of patients.”

NSCOT was supported by the National Institutes of Health. Dr. Sorensen disclosed no conflicts of interest.

SAN FRANCISCO — Nearly one-third of trauma patients reported at least some degree of sexual dysfunction a year after injury, according to a multicenter prospective cohort study.

This rate is about double that of healthy patients, and triple that of healthy patients under the age of 50 years, Dr. Matthew D. Sorenson said at the annual clinical conference of the American College of Surgeons.

“In fact, we found that a moderate to severe traumatic injury imparts a risk of sexual dysfunction above and beyond the risk that may be imparted by known risk factors for sexual dysfunction, such as increasing age, diabetes, and lower socioeconomic status,” Dr. Sorensen of the University of Washington, Seattle, said in a prepared statement.

The study was based on data from the National Study on the Costs and Outcomes of Trauma (NSCOT), which included 69 hospitals from 15 geographic regions in the United States. Patients were between 18 and 84 years of age and had moderate to severe injuries. A year following their injuries patients completed a 45-minute phone interview.

Of 10,122 patients, 3,087 (31%) answered yes to the question, “As a result of your physical health, were you limited in your ability to have sexual relations?”

Investigators then assessed whether those patients had mild or severe sexual dysfunction. For 57% of the patients with sexual dysfunction, that dysfunction was severe.

The investigators performed a multivariate analysis, adjusting for gender, race, marital status, mechanism of injury, and genitourinary injury to determine the independent predictors of severe sexual dysfunction.

As expected, spinal cord injury emerged as the best predictor of severe sexual dysfunction, with an adjusted relative risk of 3.7. But with the relative risk of 2.3, very severe injury turned out to be a better predictor of severe sexual dysfunction than did either pelvic fracture or a lower extremity fracture, both of which had relative risks of 1.5.

Other significant independent predictors of severe sexual dysfunction were age, global health status, diabetes, and income category.

Chronic pain proved to be another independent predictor of severe sexual dysfunction after the investigators adjusted for age, gender, race, comorbidities, self-reported health, mechanism of injury, injury severity, pelvic fracture, spinal cord injury, lower extremity fracture, and genitourinary injury.

Patients with pain grade II (high intensity) had 2.4 times the risk of severe sexual dysfunction than those with no pain. That adjusted odds ratio increased to 7.26 among patients with pain grade III (moderately limiting), and to 36.4 among patients with pain grade IV (severely limiting).

The investigators also found an independent association between sexual dysfunction and depression. Patients with depressive symptoms had more than seven times the risk of severe sexual dysfunction than those with no depressive symptoms. However, in response to a question from the audience, Dr. Sorensen said, “Whether it's the sexual dysfunction that's causing depression or the depression that's causing sexual dysfunction, that's all really unknown.”

The prepared statement quoted Dr. Sorensen as saying that these findings should serve as a wake-up call for physicians who treat trauma patients. “For most practitioners, both primary care and trauma physicians, sexual function is not on their radar screen, and most often they think of erectile dysfunction in men. … But sexual dysfunction is a major determinant of quality of life, impacts both men and women, and if physicians don't ask patients about their sexual health, the patients are unlikely to bring it up. This is something physicians should be asking their patients about, because there are excellent medications that work in the majority of patients.”

NSCOT was supported by the National Institutes of Health. Dr. Sorensen disclosed no conflicts of interest.

SAN FRANCISCO — Nearly one-third of trauma patients reported at least some degree of sexual dysfunction a year after injury, according to a multicenter prospective cohort study.

This rate is about double that of healthy patients, and triple that of healthy patients under the age of 50 years, Dr. Matthew D. Sorenson said at the annual clinical conference of the American College of Surgeons.

“In fact, we found that a moderate to severe traumatic injury imparts a risk of sexual dysfunction above and beyond the risk that may be imparted by known risk factors for sexual dysfunction, such as increasing age, diabetes, and lower socioeconomic status,” Dr. Sorensen of the University of Washington, Seattle, said in a prepared statement.

The study was based on data from the National Study on the Costs and Outcomes of Trauma (NSCOT), which included 69 hospitals from 15 geographic regions in the United States. Patients were between 18 and 84 years of age and had moderate to severe injuries. A year following their injuries patients completed a 45-minute phone interview.

Of 10,122 patients, 3,087 (31%) answered yes to the question, “As a result of your physical health, were you limited in your ability to have sexual relations?”

Investigators then assessed whether those patients had mild or severe sexual dysfunction. For 57% of the patients with sexual dysfunction, that dysfunction was severe.

The investigators performed a multivariate analysis, adjusting for gender, race, marital status, mechanism of injury, and genitourinary injury to determine the independent predictors of severe sexual dysfunction.

As expected, spinal cord injury emerged as the best predictor of severe sexual dysfunction, with an adjusted relative risk of 3.7. But with the relative risk of 2.3, very severe injury turned out to be a better predictor of severe sexual dysfunction than did either pelvic fracture or a lower extremity fracture, both of which had relative risks of 1.5.

Other significant independent predictors of severe sexual dysfunction were age, global health status, diabetes, and income category.

Chronic pain proved to be another independent predictor of severe sexual dysfunction after the investigators adjusted for age, gender, race, comorbidities, self-reported health, mechanism of injury, injury severity, pelvic fracture, spinal cord injury, lower extremity fracture, and genitourinary injury.

Patients with pain grade II (high intensity) had 2.4 times the risk of severe sexual dysfunction than those with no pain. That adjusted odds ratio increased to 7.26 among patients with pain grade III (moderately limiting), and to 36.4 among patients with pain grade IV (severely limiting).

The investigators also found an independent association between sexual dysfunction and depression. Patients with depressive symptoms had more than seven times the risk of severe sexual dysfunction than those with no depressive symptoms. However, in response to a question from the audience, Dr. Sorensen said, “Whether it's the sexual dysfunction that's causing depression or the depression that's causing sexual dysfunction, that's all really unknown.”

The prepared statement quoted Dr. Sorensen as saying that these findings should serve as a wake-up call for physicians who treat trauma patients. “For most practitioners, both primary care and trauma physicians, sexual function is not on their radar screen, and most often they think of erectile dysfunction in men. … But sexual dysfunction is a major determinant of quality of life, impacts both men and women, and if physicians don't ask patients about their sexual health, the patients are unlikely to bring it up. This is something physicians should be asking their patients about, because there are excellent medications that work in the majority of patients.”

NSCOT was supported by the National Institutes of Health. Dr. Sorensen disclosed no conflicts of interest.

HONOLULU — The “digital divide” separating society's haves and have-nots may not be as deep as many fear, according to a study of 120 parents of adolescent patients and the patients themselves.

In a survey, more than 60% of parents and adolescents of low socioeconomic status (SES) from one Boston pediatric practice indicated a willingness to contact physicians via e-mail if given the option, said Dr. Tarissa Mitchell of Boston Medical Center.

Among survey respondents, 66% stated that they had access to e-mail and/or computers at home. But only 19% of the parents had their health care provider's e-mail address, and only 3% had ever used e-mail to contact their provider.

Dr. Mitchell and Dr. Shikha G. Anand of the Whittier Street Health Center, Roxbury, Mass., conducted a convenience sample survey at an urban community health center in Boston over a 4-month period. At that center, five pediatric providers serve 3,876 low SES children, 84% of whom are publicly insured and 82% of whom self-identify as black or Hispanic.

Compared with respondents without e-mail availability at home, those with home e-mail availability were significantly more willing to contact their physicians: 77% vs. 33%, Dr. Mitchell and Dr. Anand wrote in a poster presented at the annual meeting of the Pediatric Academic Societies.

Only 13% of the respondents said they would never use e-mail to communicate with their provider. The most common reason given was a desire to telephone the office, but they also cited lack of access to e-mail, difficulty with the English language, concerns over bothering the doctor with e-mails, and an expectation of slower response time. In addition, 33% expressed concern that e-mail may not be private and could be reviewed by individuals other than their health care provider.

HONOLULU — The “digital divide” separating society's haves and have-nots may not be as deep as many fear, according to a study of 120 parents of adolescent patients and the patients themselves.

In a survey, more than 60% of parents and adolescents of low socioeconomic status (SES) from one Boston pediatric practice indicated a willingness to contact physicians via e-mail if given the option, said Dr. Tarissa Mitchell of Boston Medical Center.

Among survey respondents, 66% stated that they had access to e-mail and/or computers at home. But only 19% of the parents had their health care provider's e-mail address, and only 3% had ever used e-mail to contact their provider.

Dr. Mitchell and Dr. Shikha G. Anand of the Whittier Street Health Center, Roxbury, Mass., conducted a convenience sample survey at an urban community health center in Boston over a 4-month period. At that center, five pediatric providers serve 3,876 low SES children, 84% of whom are publicly insured and 82% of whom self-identify as black or Hispanic.

Compared with respondents without e-mail availability at home, those with home e-mail availability were significantly more willing to contact their physicians: 77% vs. 33%, Dr. Mitchell and Dr. Anand wrote in a poster presented at the annual meeting of the Pediatric Academic Societies.

Only 13% of the respondents said they would never use e-mail to communicate with their provider. The most common reason given was a desire to telephone the office, but they also cited lack of access to e-mail, difficulty with the English language, concerns over bothering the doctor with e-mails, and an expectation of slower response time. In addition, 33% expressed concern that e-mail may not be private and could be reviewed by individuals other than their health care provider.

HONOLULU — The “digital divide” separating society's haves and have-nots may not be as deep as many fear, according to a study of 120 parents of adolescent patients and the patients themselves.

In a survey, more than 60% of parents and adolescents of low socioeconomic status (SES) from one Boston pediatric practice indicated a willingness to contact physicians via e-mail if given the option, said Dr. Tarissa Mitchell of Boston Medical Center.

Among survey respondents, 66% stated that they had access to e-mail and/or computers at home. But only 19% of the parents had their health care provider's e-mail address, and only 3% had ever used e-mail to contact their provider.

Dr. Mitchell and Dr. Shikha G. Anand of the Whittier Street Health Center, Roxbury, Mass., conducted a convenience sample survey at an urban community health center in Boston over a 4-month period. At that center, five pediatric providers serve 3,876 low SES children, 84% of whom are publicly insured and 82% of whom self-identify as black or Hispanic.

Compared with respondents without e-mail availability at home, those with home e-mail availability were significantly more willing to contact their physicians: 77% vs. 33%, Dr. Mitchell and Dr. Anand wrote in a poster presented at the annual meeting of the Pediatric Academic Societies.

Only 13% of the respondents said they would never use e-mail to communicate with their provider. The most common reason given was a desire to telephone the office, but they also cited lack of access to e-mail, difficulty with the English language, concerns over bothering the doctor with e-mails, and an expectation of slower response time. In addition, 33% expressed concern that e-mail may not be private and could be reviewed by individuals other than their health care provider.

SAN FRANCISCO — Nearly 9 out of 10 laparoscopic surgeons said they experienced physical discomfort or symptoms related to performing surgery, according to the results of an online survey.

Feedback from 317 laparoscopic surgeons in North America and Europe who responded to the anonymous survey showed a marked increase in symptoms, compared with a 1999 study, Dr. Adrian Park said at the annual clinical congress of the American College of Surgeons.

According to that study, 8%–12% of laparoscopic surgeons reported pain or numbness and 9%–18% reported stiffness in the neck, shoulder, arm, or wrist (Surg. Endosc. 1999;13:466–8). In contrast, 42% of 2008 survey respondents reported neck stiffness. Other common complaints were numbness in the left and right hands (28% and 32%, respectively); stiffness and pain in the back (31% and 36%, respectively); and fatigue in the eyes (27%), neck (23%), left arm (24%), right arm (33%), and back (26%).

“If we were subjected to any of the kinds of worksite inspections that manufacturing facilities are … the surgical work space would be shut down,” said Dr. Park of the University of Maryland, Baltimore. “There's no question that we need to study further the ergonomics of the perioperative environment, and we need absolutely to be [studying] the surgeon-patient and the surgeon-equipment interface. It's a bit of a conjecture, but I would suggest that no less than surgical career longevity may be at risk.”

Dr. Park said the response rate was a bit under 30%; the respondents' average age was 44.3 years, and 83% were male. On average they had been in practice for 9.8 years and performed 212 laparoscopic procedures annually.

Surgeons with high caseloads were significantly more likely to report physical symptoms than those with low caseloads. Right-handed surgeons were significantly more likely to report right-hand symptoms than left-hand symptoms (54% vs. 40%). But left-handed and ambidextrous surgeons showed no significant differences in symptoms between hands.

More than 80% of the symptoms occurred during or immediately after a case, but about 15% of surgeons said that their symptoms were persistent. Unfortunately, little work has been done to identify which surgical movements are causing the problems. “Our base knowledge of surgical movement is abysmal. You can have your backhand evaluated, you can have your golf swing evaluated, but we can't tell you what optimal surgical movement is,” he said.

Dr. Park highlighted several areas that may be causing problems. Open surgery allows a surgeon to move with about 20 degrees of freedom, but in laparoscopic surgery there are only 4–6 degrees of freedom. The surgeon has a three-dimensional view in open surgery, but only a two-dimensional view in laparoscopic surgery. Laparoscopic surgeons enjoy less tactile feedback than open surgeons, and laparoscopic instruments provide less force transmission than open instruments. And the “fulcrum effect,” which requires the surgeon to move the instrument handle in the direction opposite from the desired direction of the instrument tip, may play a role.

“I've practiced minimally invasive surgery my entire career. I've already had one wrist operated on, and I'm waiting for the next wrist to be operated on,” said Dr. Park.

He disclosed that he has financial relationships with Stryker Endoscopy, Surgiquest Inc., Apollo Endosurgery Inc., and W.L. Gore & Associates.

'I've already had one wrist operated on, and I'm waiting for the next wrist [to be done].' DR. PARK

SAN FRANCISCO — Nearly 9 out of 10 laparoscopic surgeons said they experienced physical discomfort or symptoms related to performing surgery, according to the results of an online survey.

Feedback from 317 laparoscopic surgeons in North America and Europe who responded to the anonymous survey showed a marked increase in symptoms, compared with a 1999 study, Dr. Adrian Park said at the annual clinical congress of the American College of Surgeons.

According to that study, 8%–12% of laparoscopic surgeons reported pain or numbness and 9%–18% reported stiffness in the neck, shoulder, arm, or wrist (Surg. Endosc. 1999;13:466–8). In contrast, 42% of 2008 survey respondents reported neck stiffness. Other common complaints were numbness in the left and right hands (28% and 32%, respectively); stiffness and pain in the back (31% and 36%, respectively); and fatigue in the eyes (27%), neck (23%), left arm (24%), right arm (33%), and back (26%).

“If we were subjected to any of the kinds of worksite inspections that manufacturing facilities are … the surgical work space would be shut down,” said Dr. Park of the University of Maryland, Baltimore. “There's no question that we need to study further the ergonomics of the perioperative environment, and we need absolutely to be [studying] the surgeon-patient and the surgeon-equipment interface. It's a bit of a conjecture, but I would suggest that no less than surgical career longevity may be at risk.”

Dr. Park said the response rate was a bit under 30%; the respondents' average age was 44.3 years, and 83% were male. On average they had been in practice for 9.8 years and performed 212 laparoscopic procedures annually.

Surgeons with high caseloads were significantly more likely to report physical symptoms than those with low caseloads. Right-handed surgeons were significantly more likely to report right-hand symptoms than left-hand symptoms (54% vs. 40%). But left-handed and ambidextrous surgeons showed no significant differences in symptoms between hands.

More than 80% of the symptoms occurred during or immediately after a case, but about 15% of surgeons said that their symptoms were persistent. Unfortunately, little work has been done to identify which surgical movements are causing the problems. “Our base knowledge of surgical movement is abysmal. You can have your backhand evaluated, you can have your golf swing evaluated, but we can't tell you what optimal surgical movement is,” he said.

Dr. Park highlighted several areas that may be causing problems. Open surgery allows a surgeon to move with about 20 degrees of freedom, but in laparoscopic surgery there are only 4–6 degrees of freedom. The surgeon has a three-dimensional view in open surgery, but only a two-dimensional view in laparoscopic surgery. Laparoscopic surgeons enjoy less tactile feedback than open surgeons, and laparoscopic instruments provide less force transmission than open instruments. And the “fulcrum effect,” which requires the surgeon to move the instrument handle in the direction opposite from the desired direction of the instrument tip, may play a role.

“I've practiced minimally invasive surgery my entire career. I've already had one wrist operated on, and I'm waiting for the next wrist to be operated on,” said Dr. Park.

He disclosed that he has financial relationships with Stryker Endoscopy, Surgiquest Inc., Apollo Endosurgery Inc., and W.L. Gore & Associates.

'I've already had one wrist operated on, and I'm waiting for the next wrist [to be done].' DR. PARK

SAN FRANCISCO — Nearly 9 out of 10 laparoscopic surgeons said they experienced physical discomfort or symptoms related to performing surgery, according to the results of an online survey.

Feedback from 317 laparoscopic surgeons in North America and Europe who responded to the anonymous survey showed a marked increase in symptoms, compared with a 1999 study, Dr. Adrian Park said at the annual clinical congress of the American College of Surgeons.

According to that study, 8%–12% of laparoscopic surgeons reported pain or numbness and 9%–18% reported stiffness in the neck, shoulder, arm, or wrist (Surg. Endosc. 1999;13:466–8). In contrast, 42% of 2008 survey respondents reported neck stiffness. Other common complaints were numbness in the left and right hands (28% and 32%, respectively); stiffness and pain in the back (31% and 36%, respectively); and fatigue in the eyes (27%), neck (23%), left arm (24%), right arm (33%), and back (26%).

“If we were subjected to any of the kinds of worksite inspections that manufacturing facilities are … the surgical work space would be shut down,” said Dr. Park of the University of Maryland, Baltimore. “There's no question that we need to study further the ergonomics of the perioperative environment, and we need absolutely to be [studying] the surgeon-patient and the surgeon-equipment interface. It's a bit of a conjecture, but I would suggest that no less than surgical career longevity may be at risk.”

Dr. Park said the response rate was a bit under 30%; the respondents' average age was 44.3 years, and 83% were male. On average they had been in practice for 9.8 years and performed 212 laparoscopic procedures annually.

Surgeons with high caseloads were significantly more likely to report physical symptoms than those with low caseloads. Right-handed surgeons were significantly more likely to report right-hand symptoms than left-hand symptoms (54% vs. 40%). But left-handed and ambidextrous surgeons showed no significant differences in symptoms between hands.

More than 80% of the symptoms occurred during or immediately after a case, but about 15% of surgeons said that their symptoms were persistent. Unfortunately, little work has been done to identify which surgical movements are causing the problems. “Our base knowledge of surgical movement is abysmal. You can have your backhand evaluated, you can have your golf swing evaluated, but we can't tell you what optimal surgical movement is,” he said.

Dr. Park highlighted several areas that may be causing problems. Open surgery allows a surgeon to move with about 20 degrees of freedom, but in laparoscopic surgery there are only 4–6 degrees of freedom. The surgeon has a three-dimensional view in open surgery, but only a two-dimensional view in laparoscopic surgery. Laparoscopic surgeons enjoy less tactile feedback than open surgeons, and laparoscopic instruments provide less force transmission than open instruments. And the “fulcrum effect,” which requires the surgeon to move the instrument handle in the direction opposite from the desired direction of the instrument tip, may play a role.

“I've practiced minimally invasive surgery my entire career. I've already had one wrist operated on, and I'm waiting for the next wrist to be operated on,” said Dr. Park.

He disclosed that he has financial relationships with Stryker Endoscopy, Surgiquest Inc., Apollo Endosurgery Inc., and W.L. Gore & Associates.

'I've already had one wrist operated on, and I'm waiting for the next wrist [to be done].' DR. PARK

HONOLULU — The “digital divide” separating society's haves and have-nots may not be as deep as many fear.

In a study of 120 parents of adolescent patients and the patients themselves, more than 60% of parents and adolescents of low socioeconomic status (SES) from a Boston pediatric practice indicated a willingness to contact physicians via e-mail if given the option, according to Dr. Tarissa Mitchell of Boston Medical Center.

Of the respondents, 66% stated they had access to e-mail and/or computers at home. But only 19% of the parents had their health care provider's e-mail address, and only 3% had ever used e-mail to contact their provider.

Dr. Mitchell and Dr. Shikha G. Anand of the Whittier Street Health Center, Roxbury, Mass., conducted a survey of 120 parents of adolescent patients and the adolescent patients at an urban community health center in Boston over a 4-month period. At the clinic, five pediatric providers serve 3,876 low SES children, of whom 84% are publicly insured and 82% self-identify as black or Hispanic.

Compared with respondents without e-mail at home, those with home e-mail were significantly more willing to contact their physicians: 77% vs. 33%. Respondents who used e-mail more frequently also were significantly more willing to contact their provider this way. For example, among respondents whose e-mail was always on, 89% were willing to e-mail their physicians. This declined to 60% among respondents who used e-mail weekly and to 43% of those who used e-mail monthly or less frequently, the authors wrote in a poster presented at the annual meeting of the Pediatric Academic Societies.

Only 13% of the respondents said they would never use e-mail to communicate with their provider. The most common reason was a desire to telephone the office, but they also cited lack of e-mail access, difficulty with the English language, and concerns over bothering the doctor. Dr. Mitchell and Dr. Anand stated that they had no conflicts of interest.

HONOLULU — The “digital divide” separating society's haves and have-nots may not be as deep as many fear.

In a study of 120 parents of adolescent patients and the patients themselves, more than 60% of parents and adolescents of low socioeconomic status (SES) from a Boston pediatric practice indicated a willingness to contact physicians via e-mail if given the option, according to Dr. Tarissa Mitchell of Boston Medical Center.

Of the respondents, 66% stated they had access to e-mail and/or computers at home. But only 19% of the parents had their health care provider's e-mail address, and only 3% had ever used e-mail to contact their provider.

Dr. Mitchell and Dr. Shikha G. Anand of the Whittier Street Health Center, Roxbury, Mass., conducted a survey of 120 parents of adolescent patients and the adolescent patients at an urban community health center in Boston over a 4-month period. At the clinic, five pediatric providers serve 3,876 low SES children, of whom 84% are publicly insured and 82% self-identify as black or Hispanic.

Compared with respondents without e-mail at home, those with home e-mail were significantly more willing to contact their physicians: 77% vs. 33%. Respondents who used e-mail more frequently also were significantly more willing to contact their provider this way. For example, among respondents whose e-mail was always on, 89% were willing to e-mail their physicians. This declined to 60% among respondents who used e-mail weekly and to 43% of those who used e-mail monthly or less frequently, the authors wrote in a poster presented at the annual meeting of the Pediatric Academic Societies.

Only 13% of the respondents said they would never use e-mail to communicate with their provider. The most common reason was a desire to telephone the office, but they also cited lack of e-mail access, difficulty with the English language, and concerns over bothering the doctor. Dr. Mitchell and Dr. Anand stated that they had no conflicts of interest.

HONOLULU — The “digital divide” separating society's haves and have-nots may not be as deep as many fear.

In a study of 120 parents of adolescent patients and the patients themselves, more than 60% of parents and adolescents of low socioeconomic status (SES) from a Boston pediatric practice indicated a willingness to contact physicians via e-mail if given the option, according to Dr. Tarissa Mitchell of Boston Medical Center.

Of the respondents, 66% stated they had access to e-mail and/or computers at home. But only 19% of the parents had their health care provider's e-mail address, and only 3% had ever used e-mail to contact their provider.

Dr. Mitchell and Dr. Shikha G. Anand of the Whittier Street Health Center, Roxbury, Mass., conducted a survey of 120 parents of adolescent patients and the adolescent patients at an urban community health center in Boston over a 4-month period. At the clinic, five pediatric providers serve 3,876 low SES children, of whom 84% are publicly insured and 82% self-identify as black or Hispanic.

Compared with respondents without e-mail at home, those with home e-mail were significantly more willing to contact their physicians: 77% vs. 33%. Respondents who used e-mail more frequently also were significantly more willing to contact their provider this way. For example, among respondents whose e-mail was always on, 89% were willing to e-mail their physicians. This declined to 60% among respondents who used e-mail weekly and to 43% of those who used e-mail monthly or less frequently, the authors wrote in a poster presented at the annual meeting of the Pediatric Academic Societies.

Only 13% of the respondents said they would never use e-mail to communicate with their provider. The most common reason was a desire to telephone the office, but they also cited lack of e-mail access, difficulty with the English language, and concerns over bothering the doctor. Dr. Mitchell and Dr. Anand stated that they had no conflicts of interest.

SAN FRANCISCO — Fragrances, lip balm, and nickel are the allergens most responsible for allergic contact cheilitis, which is more prevalent in women.

The data come from a subset of 10,061 patients with allergic contact dermatitis who were treated and underwent patch testing between 2001 and 2004. Of those, 75 (0.7%) had a skin condition limited to the lips and at least one clinically relevant positive patch-test reaction, Dr. Joseph F. Fowler Jr. told a meeting sponsored by Skin Disease Education Foundation (SDEF).

Of those 75, 92% were female. Fragrance mix was the most common allergen with a positive patch-test result in 30% of the patients. Myroxylon pereirae (balsam of Peru) tested positive in 23%, and nickel sulfate tested positive in 22%, Dr. Fowler of the University of Louisville (Ky.) and his coauthors wrote (Dermatitis 2008;19:202-8).

Other allergens showing positive reactions in more than 5% of patients were sodium gold thiosulfate, neomycin sulfate, cobalt chloride, propylene glycol, lanolin alcohol, and cinnamic aldehyde. Makeup and lipsticks were the most common sources of allergic reactions. Jewelry was next, followed by medicaments such as neomycin and oral hygiene products such as toothpaste. Just over one-third of the patients also had another condition, including atopic diathesis and irritant dermatitis, that contributed to their lip dermatitis.

Dr. Fowler acknowledged serving as a consultant and performing clinical studies for many pharmaceutical companies. SDEF and this news organization are owned by Elsevier.

SAN FRANCISCO — Fragrances, lip balm, and nickel are the allergens most responsible for allergic contact cheilitis, which is more prevalent in women.

The data come from a subset of 10,061 patients with allergic contact dermatitis who were treated and underwent patch testing between 2001 and 2004. Of those, 75 (0.7%) had a skin condition limited to the lips and at least one clinically relevant positive patch-test reaction, Dr. Joseph F. Fowler Jr. told a meeting sponsored by Skin Disease Education Foundation (SDEF).

Of those 75, 92% were female. Fragrance mix was the most common allergen with a positive patch-test result in 30% of the patients. Myroxylon pereirae (balsam of Peru) tested positive in 23%, and nickel sulfate tested positive in 22%, Dr. Fowler of the University of Louisville (Ky.) and his coauthors wrote (Dermatitis 2008;19:202-8).

Other allergens showing positive reactions in more than 5% of patients were sodium gold thiosulfate, neomycin sulfate, cobalt chloride, propylene glycol, lanolin alcohol, and cinnamic aldehyde. Makeup and lipsticks were the most common sources of allergic reactions. Jewelry was next, followed by medicaments such as neomycin and oral hygiene products such as toothpaste. Just over one-third of the patients also had another condition, including atopic diathesis and irritant dermatitis, that contributed to their lip dermatitis.

Dr. Fowler acknowledged serving as a consultant and performing clinical studies for many pharmaceutical companies. SDEF and this news organization are owned by Elsevier.

SAN FRANCISCO — Fragrances, lip balm, and nickel are the allergens most responsible for allergic contact cheilitis, which is more prevalent in women.

The data come from a subset of 10,061 patients with allergic contact dermatitis who were treated and underwent patch testing between 2001 and 2004. Of those, 75 (0.7%) had a skin condition limited to the lips and at least one clinically relevant positive patch-test reaction, Dr. Joseph F. Fowler Jr. told a meeting sponsored by Skin Disease Education Foundation (SDEF).

Of those 75, 92% were female. Fragrance mix was the most common allergen with a positive patch-test result in 30% of the patients. Myroxylon pereirae (balsam of Peru) tested positive in 23%, and nickel sulfate tested positive in 22%, Dr. Fowler of the University of Louisville (Ky.) and his coauthors wrote (Dermatitis 2008;19:202-8).

Other allergens showing positive reactions in more than 5% of patients were sodium gold thiosulfate, neomycin sulfate, cobalt chloride, propylene glycol, lanolin alcohol, and cinnamic aldehyde. Makeup and lipsticks were the most common sources of allergic reactions. Jewelry was next, followed by medicaments such as neomycin and oral hygiene products such as toothpaste. Just over one-third of the patients also had another condition, including atopic diathesis and irritant dermatitis, that contributed to their lip dermatitis.

Dr. Fowler acknowledged serving as a consultant and performing clinical studies for many pharmaceutical companies. SDEF and this news organization are owned by Elsevier.

SAN FRANCISCO — Physician assistants and nurse practitioners can enhance the bottom line of a dermatology practice, but it is important to take a hard look at the numbers before hiring a midlevel practitioner.

At the annual meeting of the Pacific Dermatologic Association, Janet McLaughlin, a certified health care business consultant in San Francisco, discussed some of the things dermatologists should consider when hiring a physician assistant (PA) or nurse practitioner (NP).

"This is a way to enhance profitability," Ms. McLaughlin said. "Most dermatologists are about as busy as they can be, so the solution is not simply to see more patients or add more appointments in the day. Aside from the financial issues, many physicians find that [delegating routine cases to a PA or an NP] allows them to treat more of the more interesting and challenging cases."

To determine whether hiring a midlevel practitioner would be worthwhile, direct staff to monitor all new-patient calls, she advised. How many are being received each day? Are prospective patients making appointments? Or are they going elsewhere because they couldn't get appointments within a reasonable period of time?

Hiring someone on a part-time basis—perhaps 2 full days or 4 half-days—can be a good way to test the waters with minimal risk before plunging in with a full-time employee.

"One of the most common mistakes I see once these individuals are hired is not to monitor their productivity and their profitability," Ms. McLaughlin said. "It's not all about the profit, but certainly you don't want to be losing money."

Doing this is not as straightforward as it might seem. It's not a matter of simply subtracting the practitioner's salary and benefits from his or her gross receipts. To get a true picture of profitability, one must also subtract a realistic share of the practice's operating expenses.

The next question is deciding how to compensate the practitioner. In general, there are three possibilities: a straight salary, an incentive formula based on productivity, or a base salary supplemented by incentives.

If this is a new position one should start with straight salary, Ms. McLaughlin recommended, because it's impossible to predict how much revenue the midlevel practitioner will generate. Someone expecting substantial incentive income will be disappointed and might well leave after a short time if reality doesn't match expectations.

It will be more obvious after a year or so whether switching to an incentive program will work, but employees shouldn't be switched unless it's clear that they will be earning more money.

When considering an incentive program, one has to decide whether to base it on the practice's gross revenues or on departmental profit. Ms. McLaughlin expressed a strong preference for using gross revenues. Although basing compensation on departmental profit does give NPs or PAs some responsibility for keeping operating expenses down, there are many expenses that they cannot control. "You can end up with problems if you want to purchase a piece of equipment and they think, 'This is going to cut into my take, so I'm not so interested in doing it,'" she said.

It is important to compare the practitioner's billings with patients' medical records. Physician assistants and nurse practitioners are rarely trained in the art of third-party compensation, and there is a danger that they will underbill.

In commenting on Ms. McLaughlin's presentation, Dr. Ronald L. Moy, a dermatologist in private practice in Los Angeles, noted that upcoding can also be a problem, and to partly reduce that temptation, he always compensates his midlevel practitioners with a straight salary.

Dr. Moy had one final tip for working with these practitioners: "They [should] never see a new patient, because I think the biggest danger we all have is missing a melanoma or something."

SAN FRANCISCO — Physician assistants and nurse practitioners can enhance the bottom line of a dermatology practice, but it is important to take a hard look at the numbers before hiring a midlevel practitioner.

At the annual meeting of the Pacific Dermatologic Association, Janet McLaughlin, a certified health care business consultant in San Francisco, discussed some of the things dermatologists should consider when hiring a physician assistant (PA) or nurse practitioner (NP).

"This is a way to enhance profitability," Ms. McLaughlin said. "Most dermatologists are about as busy as they can be, so the solution is not simply to see more patients or add more appointments in the day. Aside from the financial issues, many physicians find that [delegating routine cases to a PA or an NP] allows them to treat more of the more interesting and challenging cases."

To determine whether hiring a midlevel practitioner would be worthwhile, direct staff to monitor all new-patient calls, she advised. How many are being received each day? Are prospective patients making appointments? Or are they going elsewhere because they couldn't get appointments within a reasonable period of time?

Hiring someone on a part-time basis—perhaps 2 full days or 4 half-days—can be a good way to test the waters with minimal risk before plunging in with a full-time employee.

"One of the most common mistakes I see once these individuals are hired is not to monitor their productivity and their profitability," Ms. McLaughlin said. "It's not all about the profit, but certainly you don't want to be losing money."

Doing this is not as straightforward as it might seem. It's not a matter of simply subtracting the practitioner's salary and benefits from his or her gross receipts. To get a true picture of profitability, one must also subtract a realistic share of the practice's operating expenses.

The next question is deciding how to compensate the practitioner. In general, there are three possibilities: a straight salary, an incentive formula based on productivity, or a base salary supplemented by incentives.

If this is a new position one should start with straight salary, Ms. McLaughlin recommended, because it's impossible to predict how much revenue the midlevel practitioner will generate. Someone expecting substantial incentive income will be disappointed and might well leave after a short time if reality doesn't match expectations.

It will be more obvious after a year or so whether switching to an incentive program will work, but employees shouldn't be switched unless it's clear that they will be earning more money.

When considering an incentive program, one has to decide whether to base it on the practice's gross revenues or on departmental profit. Ms. McLaughlin expressed a strong preference for using gross revenues. Although basing compensation on departmental profit does give NPs or PAs some responsibility for keeping operating expenses down, there are many expenses that they cannot control. "You can end up with problems if you want to purchase a piece of equipment and they think, 'This is going to cut into my take, so I'm not so interested in doing it,'" she said.

It is important to compare the practitioner's billings with patients' medical records. Physician assistants and nurse practitioners are rarely trained in the art of third-party compensation, and there is a danger that they will underbill.

In commenting on Ms. McLaughlin's presentation, Dr. Ronald L. Moy, a dermatologist in private practice in Los Angeles, noted that upcoding can also be a problem, and to partly reduce that temptation, he always compensates his midlevel practitioners with a straight salary.

Dr. Moy had one final tip for working with these practitioners: "They [should] never see a new patient, because I think the biggest danger we all have is missing a melanoma or something."

SAN FRANCISCO — Physician assistants and nurse practitioners can enhance the bottom line of a dermatology practice, but it is important to take a hard look at the numbers before hiring a midlevel practitioner.

At the annual meeting of the Pacific Dermatologic Association, Janet McLaughlin, a certified health care business consultant in San Francisco, discussed some of the things dermatologists should consider when hiring a physician assistant (PA) or nurse practitioner (NP).

"This is a way to enhance profitability," Ms. McLaughlin said. "Most dermatologists are about as busy as they can be, so the solution is not simply to see more patients or add more appointments in the day. Aside from the financial issues, many physicians find that [delegating routine cases to a PA or an NP] allows them to treat more of the more interesting and challenging cases."

To determine whether hiring a midlevel practitioner would be worthwhile, direct staff to monitor all new-patient calls, she advised. How many are being received each day? Are prospective patients making appointments? Or are they going elsewhere because they couldn't get appointments within a reasonable period of time?

Hiring someone on a part-time basis—perhaps 2 full days or 4 half-days—can be a good way to test the waters with minimal risk before plunging in with a full-time employee.

"One of the most common mistakes I see once these individuals are hired is not to monitor their productivity and their profitability," Ms. McLaughlin said. "It's not all about the profit, but certainly you don't want to be losing money."

Doing this is not as straightforward as it might seem. It's not a matter of simply subtracting the practitioner's salary and benefits from his or her gross receipts. To get a true picture of profitability, one must also subtract a realistic share of the practice's operating expenses.

The next question is deciding how to compensate the practitioner. In general, there are three possibilities: a straight salary, an incentive formula based on productivity, or a base salary supplemented by incentives.

If this is a new position one should start with straight salary, Ms. McLaughlin recommended, because it's impossible to predict how much revenue the midlevel practitioner will generate. Someone expecting substantial incentive income will be disappointed and might well leave after a short time if reality doesn't match expectations.

It will be more obvious after a year or so whether switching to an incentive program will work, but employees shouldn't be switched unless it's clear that they will be earning more money.

When considering an incentive program, one has to decide whether to base it on the practice's gross revenues or on departmental profit. Ms. McLaughlin expressed a strong preference for using gross revenues. Although basing compensation on departmental profit does give NPs or PAs some responsibility for keeping operating expenses down, there are many expenses that they cannot control. "You can end up with problems if you want to purchase a piece of equipment and they think, 'This is going to cut into my take, so I'm not so interested in doing it,'" she said.

It is important to compare the practitioner's billings with patients' medical records. Physician assistants and nurse practitioners are rarely trained in the art of third-party compensation, and there is a danger that they will underbill.

In commenting on Ms. McLaughlin's presentation, Dr. Ronald L. Moy, a dermatologist in private practice in Los Angeles, noted that upcoding can also be a problem, and to partly reduce that temptation, he always compensates his midlevel practitioners with a straight salary.

Dr. Moy had one final tip for working with these practitioners: "They [should] never see a new patient, because I think the biggest danger we all have is missing a melanoma or something."

HONOLULU — The "digital divide" separating society's haves and have-nots may not be as deep as many fear, according to a study of 120 parents of adolescent patients and the patients themselves.

In a survey, more than 60% of parents and adolescents of low socioeconomic status (SES) from one Boston pediatric practice indicated a willingness to contact physicians via e-mail if given the option, according to Dr. Tarissa Mitchell of Boston Medical Center.

Among survey respondents, 66% stated that they had access to e-mail and/or computers at home. But only 19% of the parents had their health care provider's e-mail address, and only 3% had ever used e-mail to contact their provider.

Dr. Mitchell and Dr. Shikha G. Anand of the Whittier Street Health Center, Roxbury, Mass., conducted a convenience sample survey of 120 parents of adolescent patients and the adolescent patients who were above the age of 13 at an urban community health center in Boston over a 4-month period. At that center, five pediatric providers serve 3,876 low SES children, 84% of whom are publicly insured and 82% of whom self-identify as black or Hispanic.

Compared with respondents without e-mail availability at home, those with home e-mail availability were significantly more willing to contact their physicians: 77% vs. 33%. And respondents who used e-mail more frequently also were significantly more willing to contact their provider this way.

For example, among respondents whose e-mail was always on, 89% were willing to e-mail their physicians. This declined to 60% among respondents who used e-mail only weekly and to 43% of those who used e-mail monthly or less frequently than that, Dr. Mitchell and Dr. Anand wrote in a poster presented at the annual meeting of the Pediatric Academic Societies.

Only 13% of the respondents stated that they would never use e-mail to communicate with their provider. The most common reason given was a desire to telephone the office, but they also cited lack of access to e-mail, difficulty with the English language, concerns over bothering the doctor with e-mails, and an expectation of slower response time.

In addition, 33% of the entire survey population expressed concern that e-mail may not be private and could be reviewed by individuals other than their health care provider.

Dr. Mitchell and Dr. Anand disclosed that they had no conflicts of interest related to this presentation.

HONOLULU — The "digital divide" separating society's haves and have-nots may not be as deep as many fear, according to a study of 120 parents of adolescent patients and the patients themselves.

In a survey, more than 60% of parents and adolescents of low socioeconomic status (SES) from one Boston pediatric practice indicated a willingness to contact physicians via e-mail if given the option, according to Dr. Tarissa Mitchell of Boston Medical Center.

Among survey respondents, 66% stated that they had access to e-mail and/or computers at home. But only 19% of the parents had their health care provider's e-mail address, and only 3% had ever used e-mail to contact their provider.

Dr. Mitchell and Dr. Shikha G. Anand of the Whittier Street Health Center, Roxbury, Mass., conducted a convenience sample survey of 120 parents of adolescent patients and the adolescent patients who were above the age of 13 at an urban community health center in Boston over a 4-month period. At that center, five pediatric providers serve 3,876 low SES children, 84% of whom are publicly insured and 82% of whom self-identify as black or Hispanic.

Compared with respondents without e-mail availability at home, those with home e-mail availability were significantly more willing to contact their physicians: 77% vs. 33%. And respondents who used e-mail more frequently also were significantly more willing to contact their provider this way.

For example, among respondents whose e-mail was always on, 89% were willing to e-mail their physicians. This declined to 60% among respondents who used e-mail only weekly and to 43% of those who used e-mail monthly or less frequently than that, Dr. Mitchell and Dr. Anand wrote in a poster presented at the annual meeting of the Pediatric Academic Societies.

Only 13% of the respondents stated that they would never use e-mail to communicate with their provider. The most common reason given was a desire to telephone the office, but they also cited lack of access to e-mail, difficulty with the English language, concerns over bothering the doctor with e-mails, and an expectation of slower response time.

In addition, 33% of the entire survey population expressed concern that e-mail may not be private and could be reviewed by individuals other than their health care provider.

Dr. Mitchell and Dr. Anand disclosed that they had no conflicts of interest related to this presentation.

HONOLULU — The "digital divide" separating society's haves and have-nots may not be as deep as many fear, according to a study of 120 parents of adolescent patients and the patients themselves.

In a survey, more than 60% of parents and adolescents of low socioeconomic status (SES) from one Boston pediatric practice indicated a willingness to contact physicians via e-mail if given the option, according to Dr. Tarissa Mitchell of Boston Medical Center.

Among survey respondents, 66% stated that they had access to e-mail and/or computers at home. But only 19% of the parents had their health care provider's e-mail address, and only 3% had ever used e-mail to contact their provider.

Dr. Mitchell and Dr. Shikha G. Anand of the Whittier Street Health Center, Roxbury, Mass., conducted a convenience sample survey of 120 parents of adolescent patients and the adolescent patients who were above the age of 13 at an urban community health center in Boston over a 4-month period. At that center, five pediatric providers serve 3,876 low SES children, 84% of whom are publicly insured and 82% of whom self-identify as black or Hispanic.

Compared with respondents without e-mail availability at home, those with home e-mail availability were significantly more willing to contact their physicians: 77% vs. 33%. And respondents who used e-mail more frequently also were significantly more willing to contact their provider this way.

For example, among respondents whose e-mail was always on, 89% were willing to e-mail their physicians. This declined to 60% among respondents who used e-mail only weekly and to 43% of those who used e-mail monthly or less frequently than that, Dr. Mitchell and Dr. Anand wrote in a poster presented at the annual meeting of the Pediatric Academic Societies.

Only 13% of the respondents stated that they would never use e-mail to communicate with their provider. The most common reason given was a desire to telephone the office, but they also cited lack of access to e-mail, difficulty with the English language, concerns over bothering the doctor with e-mails, and an expectation of slower response time.

In addition, 33% of the entire survey population expressed concern that e-mail may not be private and could be reviewed by individuals other than their health care provider.

Dr. Mitchell and Dr. Anand disclosed that they had no conflicts of interest related to this presentation.

SAN FRANCISCO — Intestinal-type adenocarcinoma of the ethmoid sinus appears to be strongly related to long-term occupational exposure to wood dust or leather dust, Dr. Stefano Riccio reported at the Seventh International Conference on Head and Neck Cancer.

In a case series involving 706 patients with malignant tumors of the paranasal sinuses, 92.2% of the patients with histologically confirmed adenocarcinoma of the ethmoid sinus acknowledged substantial exposure to one of these dusts, said Dr. Riccio of the National Cancer Institute of Milan.

Most patients had been exposed to organic dusts for 25–58 years in their jobs as woodworkers or shoemakers. But 17 patients reported only early and relatively limited exposure to organic dusts: from 4 to 18 years followed by 28–46 years before the appearance of disease.

In patients with nasal obstruction or small or occasional epistaxis, physicians should determine whether the patient had been exposed to any oncogenic agents in the past, Dr. Riccio recommended at the conference, which was sponsored by the American Head and Neck Society. If such exposure can be confirmed, adenocarcinoma of the ethmoid sinus should be part of the differential diagnosis.

Dr. Riccio pointed out that epidemiologists first noticed an association between wood dust and nasal cancer in 1965. But epidemiological studies rarely make anatomical distinctions among the paranasal sinuses.

On the other hand, physicians are aware that intestinal-type adenocarcinoma is peculiar to the ethmoid sinus. For the most part, however, they are unaware of the epidemiological connection with occupational exposure.

All patients in the case series were treated between 1987 and 2007 at the National Cancer Institute of Milan. The cancer originated in the ethmoid sinus 57% of the time and in the maxillary sinus 43% of the time.

Forty-five percent of the patients in the ethmoid group reported occupational exposure to wood or leather dust, compared with just 1.3% of the maxillary group, a significant difference.

Intestinal-type adenocarcinoma was the predominant histologic type in the ethmoid group, and was seen in 44% of those patients.

In comparison, squamous cell carcinoma was the most common histologic type in the maxillary group, and was seen in 35% of those patients.

In his review of the literature, Dr. Riccio found that the rate of adenocarcinoma among patients with malignant ethmoid tumors appears to be much higher in Europe than in North America. In five European case series, the rate ranged from 27% to 74%, with the lowest rate in the United Kingdom. In five North American case series, the rate ranged from 6% to 17%.

Dr. Riccio suggested the three possible explanations for this discrepancy. First, while the commonly accepted danger threshold for wood dust in Europe is 5 mg/m

Dr. Riccio stated that he had no conflicts of interest related to his presentation.

SAN FRANCISCO — Intestinal-type adenocarcinoma of the ethmoid sinus appears to be strongly related to long-term occupational exposure to wood dust or leather dust, Dr. Stefano Riccio reported at the Seventh International Conference on Head and Neck Cancer.

In a case series involving 706 patients with malignant tumors of the paranasal sinuses, 92.2% of the patients with histologically confirmed adenocarcinoma of the ethmoid sinus acknowledged substantial exposure to one of these dusts, said Dr. Riccio of the National Cancer Institute of Milan.

Most patients had been exposed to organic dusts for 25–58 years in their jobs as woodworkers or shoemakers. But 17 patients reported only early and relatively limited exposure to organic dusts: from 4 to 18 years followed by 28–46 years before the appearance of disease.

In patients with nasal obstruction or small or occasional epistaxis, physicians should determine whether the patient had been exposed to any oncogenic agents in the past, Dr. Riccio recommended at the conference, which was sponsored by the American Head and Neck Society. If such exposure can be confirmed, adenocarcinoma of the ethmoid sinus should be part of the differential diagnosis.

Dr. Riccio pointed out that epidemiologists first noticed an association between wood dust and nasal cancer in 1965. But epidemiological studies rarely make anatomical distinctions among the paranasal sinuses.

On the other hand, physicians are aware that intestinal-type adenocarcinoma is peculiar to the ethmoid sinus. For the most part, however, they are unaware of the epidemiological connection with occupational exposure.

All patients in the case series were treated between 1987 and 2007 at the National Cancer Institute of Milan. The cancer originated in the ethmoid sinus 57% of the time and in the maxillary sinus 43% of the time.

Forty-five percent of the patients in the ethmoid group reported occupational exposure to wood or leather dust, compared with just 1.3% of the maxillary group, a significant difference.

Intestinal-type adenocarcinoma was the predominant histologic type in the ethmoid group, and was seen in 44% of those patients.

In comparison, squamous cell carcinoma was the most common histologic type in the maxillary group, and was seen in 35% of those patients.

In his review of the literature, Dr. Riccio found that the rate of adenocarcinoma among patients with malignant ethmoid tumors appears to be much higher in Europe than in North America. In five European case series, the rate ranged from 27% to 74%, with the lowest rate in the United Kingdom. In five North American case series, the rate ranged from 6% to 17%.

Dr. Riccio suggested the three possible explanations for this discrepancy. First, while the commonly accepted danger threshold for wood dust in Europe is 5 mg/m

Dr. Riccio stated that he had no conflicts of interest related to his presentation.

SAN FRANCISCO — Intestinal-type adenocarcinoma of the ethmoid sinus appears to be strongly related to long-term occupational exposure to wood dust or leather dust, Dr. Stefano Riccio reported at the Seventh International Conference on Head and Neck Cancer.

In a case series involving 706 patients with malignant tumors of the paranasal sinuses, 92.2% of the patients with histologically confirmed adenocarcinoma of the ethmoid sinus acknowledged substantial exposure to one of these dusts, said Dr. Riccio of the National Cancer Institute of Milan.

Most patients had been exposed to organic dusts for 25–58 years in their jobs as woodworkers or shoemakers. But 17 patients reported only early and relatively limited exposure to organic dusts: from 4 to 18 years followed by 28–46 years before the appearance of disease.

In patients with nasal obstruction or small or occasional epistaxis, physicians should determine whether the patient had been exposed to any oncogenic agents in the past, Dr. Riccio recommended at the conference, which was sponsored by the American Head and Neck Society. If such exposure can be confirmed, adenocarcinoma of the ethmoid sinus should be part of the differential diagnosis.

Dr. Riccio pointed out that epidemiologists first noticed an association between wood dust and nasal cancer in 1965. But epidemiological studies rarely make anatomical distinctions among the paranasal sinuses.

On the other hand, physicians are aware that intestinal-type adenocarcinoma is peculiar to the ethmoid sinus. For the most part, however, they are unaware of the epidemiological connection with occupational exposure.

All patients in the case series were treated between 1987 and 2007 at the National Cancer Institute of Milan. The cancer originated in the ethmoid sinus 57% of the time and in the maxillary sinus 43% of the time.

Forty-five percent of the patients in the ethmoid group reported occupational exposure to wood or leather dust, compared with just 1.3% of the maxillary group, a significant difference.

Intestinal-type adenocarcinoma was the predominant histologic type in the ethmoid group, and was seen in 44% of those patients.

In comparison, squamous cell carcinoma was the most common histologic type in the maxillary group, and was seen in 35% of those patients.

In his review of the literature, Dr. Riccio found that the rate of adenocarcinoma among patients with malignant ethmoid tumors appears to be much higher in Europe than in North America. In five European case series, the rate ranged from 27% to 74%, with the lowest rate in the United Kingdom. In five North American case series, the rate ranged from 6% to 17%.

Dr. Riccio suggested the three possible explanations for this discrepancy. First, while the commonly accepted danger threshold for wood dust in Europe is 5 mg/m

Dr. Riccio stated that he had no conflicts of interest related to his presentation.